Post term pregnancy

by: Betelhem Ejigu

Objectives
• At the end of the class students will be able to :
• Define post term pregnancy
• Describe the etiology of postterm pregnancy
• List the complication of post term pregnancy
• Describe the management of post term pregnancy

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Definition
• Postterm pregnancy is a pregnancy that has extended beyond 42
weeks of gestation.
• Term gestation is defined as a pregnancy between 37 - 42
completed weeks (260 to 294 days) after the first day of the last
menstrual period (LMP).
• Its estimated to occur in 5% to 10% of all pregnancies.
• Postterm pregnancy is associated with increased risk of fetal,
maternal, and neonatal complications.

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Etiology
1. Wrong date
2. Fetal factors: Anencephaly, Congenital primary fetal adrenal
hypoplasia, male sex
3. Placental factor: sulfatase deficiency
4. Maternal factors:Primigravida, past prolonged pregnancy

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Physiological changes
• Placental changes

- ageing,infarcts,calcification
• Amniotic fluid changes

- oligohydramnios (diminished fetal urination),presence of

meconium
• Fetal changes

-Macrosomia(45%)
- IUGR(10%)

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Complication
Fetal
1. Increased perinatal mortality
2. Asphyxia - Uteroplacental insufficiency
3. Meconium aspiration
4. Macrosomia
5. Birth injury
6. Dysmaturity syndrome: 10 - 20 % of post term pregnancies

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• Complications of dysmaturity syndrome:
- Umbilical cord compression
- Short term complications: hypoglycemia, seizure, respiratory
insufficiency
- Long term complications: neurologic sequaele
- Metabolic complications: hypoglycemia, hypocalcemia

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Maternal
• Prolonged labor

• Feto-pelvic disproportion
• Increase risk of operative delivery
• Genital tract injury
• Postpartum hemorrhage

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Diagnosis
• The diagnosis is based on accurate gestational dating.
• The most common methods to determine the gestational age are

1. Knowledge of the date of the LNMP

2. Early ultrasound assessment performed before the 24th week of
gestation (preferably CRL measurement before 14weeks).

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Fetal maturity -ACOG criteria:
1. Urine/ serum hcG positive first: 36 weeks has to lapse
2. FHB positive 1st : by Doppler (30 weeks), pinnards(20 wkS)
3. Ultrasound: 1st trmester- CRL(6-11wks) GS; 2nd trimester(11-20
wks)
4. Biochemical: L/S ratio, Phosphatidyl glycerol

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Management
1. Induction of labor
- Performed at 42 weeks if the cervix is favorable.
- If the cervix is unfavorable (bishop score≤5), ripen the cervix
before induction.
- Elective cesarean delivery if indicated
2. Expectant management
- Antenatal testing is twice weekly between 41 and 42 weeks
gestation.

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• Intrapartum management:
- During labour and delivery the fetal condition should be
followed closely.
- FHB follow up with CTG or strict one to one follow up

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Hyperemesis gravidrum
Objectives
• At the end of the session students will be able to :
• Define hyperemesis gravidrum
• Describe the etiologies and risk factors of HG
• Describe the diagnosis of HG
• understand management of HG

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Introduction
• Morning sickness: is the nausea felt by about 50% of pregnant
women on getting up in the morning.
• Emesis gravidarum: actual vomiting in the morning. .

• Hyperemesis Gravidarum (HG) is severe form of nausea and

vomiting during pregnancy resulting in dehydration and weight loss.
• These two conditions usually start between the 4th and 6th weeks
of pregnancy and improves or disappears about the 12th week

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ETIOLOGY
• The following theories were postulated:
1. Hormonal: high human chorionic gonadotrophic (hCG)
stimulates the chemoreceptor trigger zone in the brain stem
including the vomiting center.
• This is the most accepted theory and proved by the higher frequency
in the conditions where the hCG is high as in;
- Early in pregnancy
- Vesicular mole and Multiple pregnancy

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2. Allergy: to the corpus luteum or the released hormones.
3. Deficiency: Adrenocortical hormone and/or Vitamin B6 and B1
4. Nervous and psychological: due to
- Psychological rejection of an unwanted pregnancy
- Fear of pregnancy or labor so it is more common in primigravida

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RISK FACTORS
• Multiple pregnancy
• Previous History
• Family History
• Overweight
• Young age
• Primigravity
• Molar pregnancy / trophoblastic disease

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DIAGNOSIS
Sign and Symptoms
• Severe nausea and vomiting even without eating.
• Dehydration: Loss of skin elasticity, sunken eyeballs, dry mucus
membranes
• Weight loss
• Rapid and weak Pulse, Low Blood pressure
• Head ache /Confusion/

• Fainting
.
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Investigations
• Urinalysis
• Stool Exam
• CBC
• RBS
• Electrolytes- serum potassium, sodium, chloride
• RFT,LFT
• Pelvic ultrasound

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DIFFERENTIAL DIAGNOSIS (DDX)
• Cholecystitis
• Appendicitis
• Pyelonephritis
• Gastroenteritis
• Gall bladder diseases
• Complicated ovarian tumours

• NB: The diagnosis of hyperemesis is considered after exclusion of

other causes of nausea and vomiting during pregnancy

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Management
Outpatient
• Infuse first liter over 1-2 hours and then 1000 mls over 4 hours
(i.e. 2 litres over 5 to 6 hrs) followed by urine ketone testing.
• Discharge the patient from with PO antiemetics medications and
dietary advice

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Inpatient
Indications for admission
• Weight loss > 5% from pre-pregnancy
• Ketonuria above +2
• Electrolyte imbalance
• Deranged renal and liver function tests
• Persistent vomiting / failed OPD management

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Fluid management

• Oral feeding withheld for 24 to 48 hrs

• Give 1 to 2 liters of NS or RL within 1 - 2 hrs

• Give maintenance fluid after deficit is corrected

• Avoid dextrose containing fluid until thiamine is supplemented with

the initial rehydration fluid

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Antiemetics
• First line
- Meclizine 25mg IV TID
- Metoclopramide- 5–10 mg IV TID
- Promethazine 5-10 mg IM every 6-8hrs
• Second line

- Serotonin antagonists - ondansetron 4-8 mg IV or PO, TID

• Third line
- Chlorpromazine 25mg IV or IM QID.

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• Electrolyte management -depends on the electrolyte abnormality

detected on lab tests

• Vitamins - Thiamine (vitamin B1)and Vitamin B6

• Diet - PO diets that minimize nausea and vomiting can be resumed

after a short period of gut rest.

Criteria for Discharge

• Improvement of ketone level in the urine

• Tolerating oral fluids and possibly food for at least 24 hrs

• Appropriate anti-emetic to be taken at home should be given for at

least one week 27

COMPLICATIONS
Maternal
• Esophageal tear or rupture
• Peripheral neuropathy due to B6 and B12 deficiency
• Wernicke's encephalopathy
• Liver and renal failure
Fetal - Preterm deliveries , Miscarriages , Fetal growth retardation and
Fetal death

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